“ACEing” Complex Population Management Past, Present, and Possible Future for ACE Models of Care UNTHSC Geriatric Grand Rounds March 25, 2015 Kellie L. Flood, MD Associate Professor Geriatric Quality Officer, UAB Hospital Director, Geriatric Medicine Section Division of Gerontology, Geriatrics, and Palliative Care University of Alabama at Birmingham Learning Objectives Define the components of an Acute Care for Elders (ACE) Unit List outcomes from clinical trials evaluating the ACE Unit model of care Discuss the new role of ACE Units in reducing unplanned readmissions and complex population management Page 2 In what year did these statements appear in a health care administration publication? “The overwhelming needs of the aging population have led to increasing expenditures for hospital care….” “How this growing elderly population will obtain and pay for health care is emerging as a major social issue……” “This changing financial and demographic trend, coupled with the limited resources provided for the elderly population, has been called the “Geriatric Imperative”” Bachman et al, Hospital and Health Services Administration 32(4):509-20. Page 3 1987 1987 Stock Market Crash Simpsons Debut on TV Gallon of Gas 88¢ BAD Album Released Movie Good Morning Vietnam Released Page 4 2014: Healthcare Did Not Heed the Warning Silver Tsunami is Here 10,000 Baby Boomers will turn 65 years old every day until 2031 If you can’t stop the wave… Learn to SURF! Page 5 Is it just a numbers thing? Older Adults Are A Different Patient Population Just As Pediatric Patients Are 62% of older Americans are experiencing multimorbidity Medicare expenditures for beneficiaries with different numbers of chronic conditions 1% 3% 6% 0 10% 1 2 3 12% 4 5+ 68% Older adults experiencing multimorbidity consume 96% of the Medicare budget Boult et al, The Permanente Journal Winter 2008;12:50-4; Boyd et al, Guided Care for Multimorbid Older Adults, Gerontol, 2007 Page 7 Older Adults are More Likely to Experience Geriatric Syndromes Dementia Delirium Depression Gait and balance abnormalities/Falls Frailty/Functional Decline Malnutrition Pressure ulcers Polypharmacy Incontinence Caregiver Stress Geriatric Syndromes = Increased Risk for Adverse Outcomes Kresevic et al, Ger Nursing, 1998 Page 8 Is it just an age thing? Older Adults Are a More Heterogeneous Patient Population Than Younger Adults Functionally and Cognitively Intact (some - maybe not much - room to spare) Functionally or Cognitively Impaired (no margin for error = vulnerable) Page 10 Why do We Need Evidence-Based Geriatric Care Models?? Perfect Storm Page 11 We Must Think Outside the Box!! Page 12 Coordinating Person-Centered Elder Care Requires an Inter(Trans)disciplinary Team Page 13 Types of Teams in Healthcare Uniprofessional: Group of people all from the same discipline working together Multiprofessional: Group of people from different disciplines who develop a treatment plan independently Interprofessional: Group of people from different disciplines assess and plan care in a collaborative manner Transprofessional: Although roles are specialized, everyone is prepared to step in/replace each other when necessary; Team leadership varies with the situation – OK to get outside your lane a bit GITT Curriculum: Teams and Teamwork; Klarare A. et al, J Pall Med 2013;16(9):1062-1069 Page 14 Transprofessional “I have learned the importance of the effects of polypharmacy in the care and treatment of UAB's geriatric patients…….. A patient's life may be changed due to medications.” - UAB Trauma Unit Occupational Therapist, 2013 Page 15 Transprofessional “One of the best things I have learned was about the different routes and half-life of IV compared to po pain meds. Last week I was able to counsel a patient and her daughter on the benefits of transitioning off IV pain meds.” - UAB ACE Unit Social Worker, 2014 Page 16 What is an ACE Unit? A Model of Inter/Transprofessional Coordinated Care in the Hospital Functional Older Person Depressed Mood Negative Expectations Acute Illness, Possible Impairment Hospitalization: ACE Unit Prehab Program: Specialized environment Patient-centered, interdisciplinary care Multi-dimensional geriatric assessment and nonpharmacologic management with nurse driven care Daily medical review Care transition planning from day 1 Improved Mood Positive Expectations Adapted from slide by SUMMA Health Care Reduced Impairment Functional Older Person Decreased Iatrogenic Risk Factors ACE Acute Care for Elders Page 17 Participants: UAB ACE Interdisciplinary Team Meeting Geriatrician/Geriatric NP ACE Unit Coordinator Nurses Rehabilitation Services (PT, OT) Pharmacist Dietician (intermittently) Social Worker Pastoral Care (intermittently) Psychology Interns (intermittently) Trainees from all disciplines Page 18 Admit to ACE Bedside Fxn and Cogn Screen UAB Hospitalist ACE Unit Process Discussed in daily IDT Care transition planning begins Day 1 based on screens - Katz ADLs - Lawton IADLs - Six Item Screener Formal geriatric consult for complex cases ACE Coordinator ensures plan implemented Existing/new/risks for geriatric syndromes identified Geri care and transition planning revised daily Page 19 Acute Care for Elders (ACE) Units are a team model of coordinated geriatric care in the hospital setting originally designed to maintain patient functional status during hospitalization ACE Unit: Randomized Controlled Trial Change in ADL performance from admission to discharge (p=0.009) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Much Worse Worse Unchanged Better Much Better ACE Unit Usual Care Secondary Outcome SNF/rehab/LTC placement: 14% ACE Unit vs 22% Usual Care (p=0.01) Landefeld et al, NEJM, 1995 Page 21 ACE in a Community Hospital 1531 community-dwelling patients age ≥ 70 admitted for acute medical illness Randomized to ACE vs Usual Care Demonstrated improved processes of care in the intervention unit Reduced use of restraints Fewer high risk meds Earlier and more frequent involvement of physical therapy and social work Improved patient and provider satisfaction Counsell et al, JAGS, 2000 Page 22 Health Care Utilization and ACE Retrospective, case-control study Academic urban hospital 680 ACE vs 680 non-ACE patients age ≥ 65 Matched for age, ethnicity, comorbidity, and DRG (CHF, pneumonia, UTI) ACE patients: Shorter mean LOS (4.9 ± 4.3 vs 5.9 ± 4.5 , p=0.01) 9.7 % reduced unadjusted mean costs ($13,586 vs $15,040; p=0.012) No difference in mean number of unadjusted readmissions 11% reduced readmission rate after controlling for age, race, comorbidity, and pre-admission rate Jayadevappa et al, Value in Health, 2006;9:186-192 Page 23 Page 24 UAB ACE Study Comparison of ACE vs Usual Care: FY 10 ACE Unit Usual Care 25 39.2% 20 40.3% Unit nursing staff allotment (WHPPD) 9.75 9.75 Physical therapists FTE: bed ratio 1:19 1:26 Hospitalists Hospitalists Yes Yes Evidence-based delirium prevention care processes Yes No Volunteer mealtime assistance program Yes No Daily Geriatrician led IDT Rounds for Geriatric Care Management Yes No Counselor for patients/families Yes No Number of beds % patients age 70 Attending Physician Formal Geriatric Consultation available upon request Flood et al, JAMA Int Med 2013;173:981-7. Page 25 Patient Characteristics ACE vs UC FY 10: Age ≥ 70 who spent entire hospital stay on ACE or UC Variables Mean (SD) or % ACE (N=428) UC (N=390) P value 81.6 (6.9) 80.9 (6.8) 0.11 Gender (Female) 69.4% 65.9% 0.29 Race (White) 64.5% 59.2% 0.30 Comorbidity Score 3.4 (3.2) 3.1 (3.0) 0.14 Case Mix Index 1.1 (0.5) 1.1 (0.6) 1.00 Age (years) No significant differences in patient characteristics between groups Flood et al, JAMA Int Med 2013;173:981-7. Page 26 Cost and Readmission Outcomes ACE vs Usual Care FY 10: Age ≥ 70 who spent entire hospital stay on ACE or UC All DRGs Top 25 DRGs Variables Mean (SD) or % ACE (N=428) UC (N=390) P Value ACE (N=260) UC (N=214) P Value LOS (days); Mean (SD) 4.0 (2.7) 4.2 (2.8) 0.34 3.7 (2.4) 4.1 (2.8) 0.11 $2,109 $2,480 $1693 $2138 Variable Direct Cost/ Case ($); Mean (SD) Daily Variable Direct Cost/Case ($); Mean (SD) Patients readmitted to UAB within 30 days of discharge 0.009 <.001 ($1,870) ($2,113) ($1063) ($1431) $542 $595 $484 $545 0.01 ($383) ($227) 7.9% 12.8% <.001 ($162) ($120) 7.3 11.2 0.02 Flood et al, JAMA Int Med 2013;173:981-7. 0.14 Page 27 Cost Savings from ACE Model Variable Direct Cost Savings = $371/case ~ $371,000 savings in variable direct cost for every 1000 patients If UC patients experienced ACE model Number of patients age ≥ 65 discharged from ACE Unit 1461 1600 1134 1400 1200 1148 918 Inpts 1000 Obs 800 600 400 216 313 Total 200 0 FY 12 FY 13 Page 28 So how can the ACE model, originally designed to maintain patient functional status, possibly impact readmissions? Readmission Patterns for Older Adults with AMI, CHF, and Pneumonia Medicare claims data from 2007-2009 to determine patterns Mean age of readmitted patients = 80 yrs for all DRGs studied Most readmits within first 15 days for all studied DRGs Dharmarajan et al, JAMA 2013;309(4):355-63. Page 30 Study Authors’ Thoughts: “The broad range of acute conditions responsible for readmission may reflect post-hospitalization syndrome – a generalized vulnerability to illness among recently discharged patients, many of whom have developed new impairments both during and after hospitalization.” Losses in mobility/functional status, nutritional status, delirium, adverse drug events, etc. Aren’t these what ACE Units address? “The heightened vulnerability to a diversity of illnesses may explain why interventions that are broadly applicable to many conditions with multiple components or are delivered by a multidisciplinary team are more likely to reduce readmissions.” Dharmarajan et al, JAMA 2013;309(4):355-63. Page 31 ACE Unit Models of Care Have Been Shown to: Improved functional performance at discharge Improved likelihood of living at home after discharge Reduced restraint use Reduced high-risk medication use Improved nutritional support during hospitalization Improved patient and provider satisfaction Reduced length of stay Reduced health care utilization costs Reduced 30-day readmissions Landefeld et al, N Engl J Med 1995; Counsell et al, JAGS 2000; Jayadevappa et al, Value in Health, 2006; Flood et al, Crit Rev Onc/Heme 2010; Flood, et al, Am J Geriatr Pharmacother 2009; Baztan et al, BMJ 2009; Flood et al, JAMA Int Med 2013. Page 32 What is the future for ACE? Helping hospitals address complex population management via: Higher Valued Care Quality Cost Possible Means of Leveraging ACE Model for Higher Valued Care Hospital-Wide ACE for non-general medical patient populations Oncology-ACE Stroke-ACE Ortho-ACE ACE of Hearts Etc, etc “e-Geriatrician” using ACE Tracker “Mobile ACE” Consultative Care UAB “Virtual ACE” Pilot Page 34 “Acefying” a Hospital via “Virtual ACE” First UAB Virtual ACE Unit: Orthopedic Surgery Geriatric Info Now Feeds into the Unit ACE Tracker Report Page 36 Key Geriatric Syndromes in Virtual ACE Training and Intervention The “Why” Function/Safe Mobility Pain Management Delirium Care Transitions Delirium Toolbox Page 37 Virtual ACE Ortho Unit Staff Feedback “Before the ACE we had delirium cases so frequently, now cases have tremendously subsided.” “Getting them moving early on has increased their satisfaction with the care at UAB and makes their pain much better. Appetite improves too.” “Just the awareness of delirium prevention has opened our eyes to things we wouldn’t have noticed before. As a unit it seems everyone is working well together by implementing these initiatives. It’s easy to become complacent if you don’t know how to work effectively with a geriatric patient, but the ACE initiative has made us excited to make changes and actively see results.” “Toolbox is a great thing to have ” Page 38 Measuring Outcomes: Pre- and Post- Pilot Test of Virtual ACE Intervention Variable* Pre (N=31) Age Mean Range Gender H/o Fall in last 3 months Baseline Katz Score (Mean) Current Katz Score (Mean) % Abnormal Six Item Screen on Admission Post (N=94) P-Value 71.5 ± 5.9 65-89 74.2 ± 7.1 65-94 P=.055 55% F 54%F NS 48% Yes 48% Yes NS 9.89 ± 3.7 9.9 ± 3.5 NS 6.55 ± 5.1 6.9 ± 4.3 NS 21% 20% NS *Variables have missing data for some patients Page 39 Early Process Outcomes: 8 Weeks Pre- and 20-Weeks Post-Training 100% 88% 80% 88% 94% 74% 60% 45% 40% 20% 0% 0% Both Baseline and Current Katz Completed NUDESC Completed Pre-Intervention Post-Intervention (wks 1-4) Post-Intervention (Katz - wks 5-12; NUDESC wks 5-20) Page 40 Mobility in the Prior 24 Hours: All Patients Pre: 43 assessments in 31 patients; Post: 30 assessments in 26 patients Pre vs Post Baseline Katz 10.4 ± 3.2 vs 11.23 ± 2.3, p=.278 Pre vs Post Current Katz 7.0 ± 5.1 vs 7.3 ± 4.3, p=.831 Page 41 2014 Ortho Unit Fall Rate for ≥ 65 years of age Virtual ACE Safe Mobility Training Page 42 39% Relative Reduction in Delirium Prevalence Pre-Training: 38 NUDESC Screens in 31 patients Post-Training: 62 NUDESC Screens in 68 patients Page 43 2014 Ortho Unit Restraint Usage Virtual ACE Delirium Training Page 44 Potential Cost Savings from Delirium Prevention UAB Hospital Discharged 19,880 patients age ≥ 65 in FY 13 Reducing Delirium from 18% to 11% Reduces delirium cases from 3,578 to 2,187 + $2,500* cost/patient $3,477,500 saved JUST from delirium aspect of their care *Rubin JAGS 2006 Page 45 Learning Objectives Revisited Define the components of an Acute Care for Elders (ACE) Unit Interdisciplinary, patient-centered, multi-dimensional geriatric assessment, non-pharmacologic management, daily medical review, and care transition planning from day 1 List outcomes from clinical trials evaluating the ACE Unit model of care Improved functional status, processes of care, med safety, likelihood of living at home after discharge, and reduced costs Discuss the new role of ACE Units in reducing unplanned readmissions and complex population management ACE appears to reduce readmissions via recognition and management of “post-hospitalization syndrome” Improved outcomes provide leverage to disseminate ACE to non-medical patient populations and throughout an entire hospital Page 46 QUESTIONS? UAB Hospital 1,156 beds of complex population management Page 47